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Surgery > Ciculation and lymphatic systems > Flashcards

Ciculation and lymphatic systems Flashcards

1
Q

Signs of chronic venous insufficiency

A

L - lipodermatosclerosis
E - eczema
G - gaps in the skin (ulceration)
S - swelling

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2
Q

Indications for preoperative Duplex USS of varicose veins?

A
  • DVT history
  • signs of chronic venous insufficiency
  • recurrent varicose veins
  • to clarify SSV or LSV incompetency
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3
Q

Varicose veins treatment

A

Conservative
- grade II graduated elastic compression stockings
- weight loss, regular exercise
Sclerotherapy
- 1% sodium tetradecyl sulphate
- for post-op recurrence
- for below knee varicosities if LSV + SSV not involved
Surgical
- ligation of SFJ or SPJ and vein stripping
- ligation of incompetent perforating vessels
- subcutaneous endoscopic perforator surgery (SEPS)

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4
Q

Syndrome associated with varicose veins

A 
Kippel-Trenaunay-Weber syndrome
- varicose veins
- port wine stains
- bony + soft tissue hypertrophy of limbs
- significant oedema
Parkes-Weber syndrome
- multiple AV fistulae
- limb hypertrophy
- can lead to high output cardiac failure
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5
Q

Venous ulcer causes

A

Deep venous insufficiency

  • Valvular disease: varicose veins, deep vein reflux, communicating vein reflux
  • Outflow tract obstruction: post-DVT
  • Muscle pump failure: primary (stroke, neuromuscular disease), secondary (musculoskeletal pathology/ankle injury)
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6
Q

Venous ulcer treatment

A

Non-surgical: 50-70% healed at 3mths, 80-90% at 12mths
- avoid trauma
- four-layer compression bandaging
- rest and leg elevation
- once healed, grade II compression stockings for life
Surgical
- if ulcer fails to heal, exclude other causes +/- biopsy
- debridement + split skin graft
- if due to primary varicose veins, treat them

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7
Q

Four-layer compression bandaging layers

A
  • non-adherent dressing over ulcer plus wool bandage
  • crepe bandage
  • blue-line bandage
  • adhesive bandage to prevent other layers slipping
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8
Q

How to measure ABPI

A
  • inflate cuff over upper arm, measure systolic pressure with doppler at brachial artery
  • inflate cuff over calf, measure systolic pressure with doppler at dorsalis pedis
  • find doppler sound, inflate cuff till disappears, slowly deflate till sound restarts = sys pressure
  • ankle/brachial = ABPI
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9
Q

Significance of ABPI

A
  • normal = 1
  • ratio falls as perfusion to leg falls
  • intermittent claudication = 0.5-0.8
  • rest pain = <50 mmHg
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10
Q

Why are diabetics prone to foot pathology?

A
  • diabetic neuropathy
  • peripheral occlusive arterial disease
  • Charcot neuroarthropathy
  • osteomyelitis
  • foot ulceration
    Can lead to amputation
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11
Q

Aetiology of diabetic foot ulcers

A
  • neuropathic (45-60%)
  • ischaemic (10%)
  • mixed neuroischaemic (25-45%)
    Diabetic neuropathy is due to (1) microvascular disease leading to nerve hypoxia, and/or (2) direct effects of hyperglycaemia on neuronal metabolism
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12
Q

Why are peripheral pulses preserved in diabetics?

A

Calcification of the walls of the vessels - prevents cuff compressing vessels = abnormally high ABPI.
Also seen in CRF

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13
Q

Differences in peripheral vascular disease in diabetics?

A
  • Intra-arterial digital subtraction angiography indicated earlier.
  • Aggressive treatment of infections
  • Meticulous foot care + chiropodist
  • Sepsis treated with surgical debridement
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14
Q

Are their any problems with diabetics undergoing angiography?

A
  • if renal impairment, can be dramatically worsened by intra-arterial contrast
  • well-hydrate patients with IV fluids peri-procedure
  • stop metformin
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15
Q

Indications for amputation

A

4 D’s

  • Dead (ischaemic): PVD, thromboangitis obliterans, AV fistulae
  • Damaged (trauma): unsalvageable limb, burns, frostbite
  • Dangerous (malignancy): bone, soft tissue
  • Damn nuisance (infection/neuropathy): osteomyelitis, nec fasc, charcot neuropathy
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16
Q

Complications of amputations

A 
Patients often have other medical problems which increases risk. Operative mortality 20%, 1 year 50%
Early
- psychological + social
- haematoma + infection
- DVT + PE
- phatom limb pain
- skin necrosis
Late
- osteomyelitis
- stump ulceration
- stump neuroma
- fixed flexion deformity
- difficulty mobilising
- spurs + osteophyte formation
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17
Q

Intermittent claudication differential

A

Leg pain can be dividied into:

  • Musculoskeletal: specific joint pathology e.g. OA
  • Neurological: spinal stenosis (leading to spinal claudication)
  • Vascular: intermittent claudication, DVT
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18
Q

Why do patients with rest pain typically get more severe pain at night?

A

Reduction in perfusion due to:

  • reduced effect of gravity lying down
  • reduced cardiac output at night
  • dilation of skin vessels due to warm bedding
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19
Q

In which patients are AAA most common

A
  • men
  • > 60
  • smokers
  • hypertensives
  • family history
20
Q

Who should have AAA’s repaired?

A
  • symptomatic aneurysms (back pain, tenderness, distal embolic events, rupture/leak)
  • asymptomatic (>5.5 cm diameter, increase >1 cm per year)
  • 10% risk of rupture per year for aneurysm >5.5cm
21
Q

Operative mortality of AAA repair?

A
  • elective = <5%
  • 50% if ruptured, but only 50% reach hospital alive
  • mortality from haemorrhage, MI, renal failure
22
Q

Alternative to open AAA repair?

A

Endovascular repair is equivalent to open repair for overall survival but has higher rate of secondary interventions. Good for high operative risk patients as less invasive

23
Q

Screening for AAA

A 
One-time USS for men >65
t rescreen
2.6-2.9 - 5 yearly
3.0-3.4 - 3 yearly
3.5-4.4 - 12 monthly
4.5-5.4 - 6 monthly
5.5+ - repair
24
Q

Investigations for carotid bruit

A
  • Urinalysis: protein
  • ECG: AF, ischaemia, LVH
  • Bloods: FBC, U+Es, glucose, lipids
  • Carotid duplex scan
  • Carotid angiography (2% stroke risk)
  • MRA
  • Echo
  • CT/MRI brain: looking for old infarcts
25
Q

Consequence of carotid stenosis?

A

85% stokes thromboembolic caused by artherosclerosis at carotid bifurcation

26
Q

Which patients are considered for carotid endarterectomy?

A
  • symptomatic carotid stenosis 70-99%
  • consider in patients with 50-70% stenosis
  • no evidence in asymptomatic patients or stenosis <50%
27
Q

What would you warn patient of in consenting them for an endarterectomy?

A
  • advantages are a 6 fold reduction in stroke at 3 years
  • operative risk of stroke is 2%, mortality 1%
  • specific risks include: haematoma, hypoglossal nerve injury, numbness of ipsilateral earlobe
28
Q

How do patients with popliteal aneurysms present?

A
  • 80% of all non-aortic aneurysms
  • lump behind knee
  • 50% present with distal limb ischaemia from thrombosis or embolism
  • may present with acute ischaemic leg
  • <10% rupture
29
Q

When and how are popliteal aneurysms treated?

A
  • symptomatic aneurysms
  • if contain thrombus
  • > 2cm
    Repaired by excision bypass (with graft), or resection and anastomosis (Hunter’s ligation)
30
Q

Causes of ischaemic ulcers

A 
Large vessel
- atherosclerosis
- thromboangiitis obliterans
Small vessel
- DM
- polyarteritis nodosa
- RA
31
Q

Treatment of ischaemic ulcers

A 
Analgesia
- very painful
- WHO analgesic ladder, combinations given regularly in variety of formulations
Risk-factor modification
- stop smoking
- good DM control
- optimize lipids
Symptom modification
- avoid drugs e.g. beta blockers
- low-dose aspirin
- iv prostaglandins (anti-platelet, vasodilators)
- lumbar sympathectomy (reduces vascoconstriction)
32
Q

Causes of gangrene

A
  • diabetes (commonest)
  • embolus + thrombus
  • Raynaud’s syndrome
  • thromboangiitis obliterans
  • ergot poisoning
  • vessel injury due to extreme cold, heat, trauma, pressure
  • drugs e.g. warfarin
33
Q

What is Fournier’s gangrene

A
  • rare necrotising subcutaneous infection involving the scrotum, penis and perineum
  • scrotum is red and swollen with crepitus on palpation
34
Q

Raynaud’s terminology

A 
Phenomenon = characteristic cold-induced changes
Disease = primary occurring in isolation
Syndrome = secondary associated with other diseases
35
Q

Pathogenesis of Raynauld’s

A

Either: normal vessels, over-active alpha receptors = abnormal smooth muscle contraction (Primary)
OR: fixed obstruction in vessel wall, reduces distal flow (Secondary)

36
Q

Raynaud’s secondary causes

A
  • Blood disordersL polycythaemia
  • Arterial: atherosclerosis, thromboangiitis obliterans
  • Drugs: beta-blockers, COCP
  • CTD: RA, SLE, scleroderma, PAN
  • Trauma: vibration injury
37
Q

Raynauld’s treatment

A 
Conservative
- gloves + warm pads in winter
- remove predisposing drugs
- smoking cessation
Medical
- CCB: nifedipine
- Prostacyclin analgues
- Alpha-blockers
- 5HT anatagonists
Surgical
- cervical sympathectomy
- amputation if digits threatened by gangrene
38
Q

Causes of neuropathic ulcers

A 
Any cause of peripheral neuropathy
Systemic disease
- Diabetes
- Vasculitis (SLE)
- Hypothyroidism
- Vit B12 deficiency
Drugs and toxins
- Amiodarone, metronidazole
- Alcohol
Infections: TB, leprosy, HIV
Paraneoplastic
Idiopathic
39
Q

Differential of swollen legs

A
  • Central: RHF, hypoalbuminaeia, nephrotic syndrome, hypothyroidism
  • Peripheral causes: venous disease: DVT, Klippel-Trenaunay syndrome, chronic venous insufficiency
  • Rare causes: angio-oedema, AV malformations (Parkes-Weber), hemi-hypertrophy
40
Q

Causes of lymphoedma

A 
Primary = congential = Milroy's disease (F:M = 3:1)
Secondary:
- Malignancy: lymph node infiltration
- Infection: filiaris, TB
- Iatrogenic: post-surgery, radiotherapy
41
Q

Lymphoedema treatment

A

Non-surgical
- grade III compression stocking
- intermittent pneumatic compression device
- treat any cellulitis
- elevate leg as much as possible, good foot care
Surgical
- direct lymphovenous anastomosis
- small intestine submucosal plexus implantation can ‘replace’ a lymph node as forms new connections with distal lymphatics
- debulking of subcutaneous tissue +/- skin

42
Q

Hyperhidrosis differential

A
  • anxiety
  • hyperthryoidism
  • phaeochromocytoma
  • hyperhidrosis erythematosus traumatica: vibration causes excess sweating, occupational
43
Q

Hyperhidrosis treatment

A
  • Reassurance
  • Aluminium hexachloride for axillary
  • Excise axillary hair-bearing skin and/or intradermal Botox
  • Cervical sympathectomy (T2-4) for palmar
  • Lumbar sympathectomy for plantar
44
Q

Side effects of cervcal sympathectomy

A
  • Excessive dryness of skin
  • Compensatory sweating around trunk
  • Horner’s syndrome (rare)
  • Pneumothorax/haemothorax
  • GA risks
45
Q

Difference between false and true aneurysm

A

Aneurysm = abnormal dilation of blood vessel
True involves all layers of arterial wall
False follows partial laceration of vessel wall causing blood to leak into surrounding tissues
False aneurysm = pulsating haematoma

46
Q

Causes of false aneurysm

A
  • Traumatic

- Iatrogenic: post angiography, post bypass surgery

47
Q

False aneurysm treatment

A
  • USS compression
  • Thrombin injection
  • Surgical repair
  • Observation and review

Surgery (4 decks)

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